Diabetes Core Update: Diabetes is Primary 2014 Part 4

Special Edition: Diabetes on a Budget; Motivational Skills

Podcast Date: September 3, 2014
Hosts: Dr. Neal Skolnick & Dr. John J. Russell
Guests: Dr. Charles Schaefer & Martha Funnell

Overview

This special episode of Diabetes Core Update features key highlights from the “Diabetes is Primary” conference. The episode focuses on two core topics: managing diabetes on a budget, presented by Dr. Charles Schaefer, and enhancing motivational skills in diabetes care, led by Martha Funnell. Through practical insights and clinical expertise, the speakers address challenges in cost-effective diabetes management and ways clinicians can inspire and empower patients for better health outcomes.

Main Discussion Points & Insights

1. Managing Diabetes on a Budget

Speaker: Dr. Charles Schaefer, University Medical Group, Augusta, GA
Timestamps: [00:49] – [10:46]

The Challenge of Diabetes and Costs

• Diabetes is expensive — medications and supplies are often costly for patients, especially those with limited insurance.
• However, initial management and prevention can be approached with minimal extra expense.

Zero-Cost and Low-Cost Interventions

• Lifestyle changes:
  • “It doesn’t cost a penny to go around the block for 30 minutes in your neighborhood every day.” ([02:17], Schaefer)
  • Diet modifications, such as reducing fatty and fried foods or simple carbohydrates, can be accomplished affordably.
  • “Weight management costs absolutely nothing.” ([02:54], Schaefer)
• Healthy eating:
  • While healthy, balanced diets can sometimes be more expensive, judicious food choices and elimination of junk food can keep costs reasonable.

Self-Monitoring of Blood Glucose (SMBG)

• SMBG is valuable but can become a significant cost.
• Monitor only when results will impact management:
  • “We ought to only be testing to attain that information, which will lead us to make some change in management.” ([04:21], Schaefer)
  • For type 2 diabetics on oral therapy, frequent readings may not change care.
• Choosing meters and strips wisely:
  • Less expensive alternatives can still be effective.

Medication Choices

• Metformin:
  • “The medication metformin can be gotten almost anywhere for no more than three or four dollars a month.” ([06:40], Schaefer)
• Sulfonylureas:
  • Although concerns exist regarding side effects, especially hypoglycemia, low-dose regimens are still budget-friendly and widely used.
  • “It’s entirely possible to get good diabetic control with metformin and low dose sulfonylurea combined.” ([08:05], Schaefer)
• Insulins:
  • Basal analog insulins are expensive, but NPH insulin is much less costly and evidence supports its efficacy.
  • “The much more expensive insulin products are no better than a very inexpensive product called NPH insulin at reducing the A1C.” ([09:08], Schaefer)
• Summary:
  • Effective diabetes management can often be achieved using affordable therapies, provided patient safety is monitored.

2. Motivational Skills in Diabetes Management

Speaker: Martha Funnell, Michigan Diabetes Research and Training Center
Timestamps: [10:50] – [20:27]

The Nature of Motivation

• Motivation is internal:
  • “Our ability to provide motivation has to rely on the patient’s internal motivation… It really becomes our job not to motivate people, but to give them messages in a way that they can use for that internal motivation. So I always think of it as our job is to be inspirational, but not motivational.” ([11:37], Funnell)
• Understanding patient perspectives:
  • Patients are always motivated, “just not motivated to do what we think they should.” ([12:45], Funnell)
  • Start by identifying what is important to the patient: their worries, concerns, and fears.

Individualizing Communication & Care

• Active listening:
  • “The most important communication skill… comes down to listening. It comes down to finding out what’s important for you… what are the other barriers and stresses in your life.” ([14:15], Funnell)
  • Recognize that diabetes may not be every patient’s top priority.
• Address diabetes-related distress:
  • Acknowledge the emotional burden and its impact on self-management.

Clinician-Patient Partnership and Empowerment

• Defining roles:
  • “There are very few jobs in the world where you wouldn't get that kind of orientation. And yet self-managing a very complex chronic disease is not one where we typically have a discussion about here's what I can do. But the reality is 99% of this is in your hands. And I need to know how to best help you to be the most effective self manager.” ([16:09], Funnell)
• Start each visit with patient’s goals:
  • While it may feel risky to let patients set the agenda, this can actually make visits more productive and efficient.
  • “Begin every visit with asking the patients what they need to accomplish during that visit. And while that’s very scary for health professionals… we know from a variety of studies that can actually shorten the visit because you accomplish what the patient needs to get addressed in the first minute or two.” ([16:55], Funnell)

Overcoming Barriers in Practice

• Time constraints:
  • Use available time to break repetitive patterns and experiment with new approaches to patient engagement.
• Team-based care:
  • Rely on the broader healthcare team—care managers, educators, etc.—to support patients.
  • “Nobody can do this alone. It truly takes a team… That’s what patients in our medical homes are all about.” ([19:27], Funnell)
• Clinician adaptability:
  • “In reality, we need to do things differently if we want to see the kind of changes in the outcomes that we want.” ([20:03], Funnell)

Notable Quotes & Memorable Moments

• On affordable lifestyle interventions:
  • “It doesn’t cost a penny to go around the block for 30 minutes in your neighborhood every day.”
    — Dr. Charles Schaefer ([02:17])
• On the cost-effectiveness of medications:
  • “The much more expensive insulin products are no better than a very inexpensive product called NPH insulin at reducing the A1C.”
    — Dr. Charles Schaefer ([09:08])
• Motivation as internal, not external:
  • “Our job is to be inspirational, but not motivational.”
    — Martha Funnell ([11:59])
• Everyone is motivated—just perhaps not in the clinician’s direction:
  • “Everybody’s motivated. They’re just not motivated to do what we think they should.”
    — Martha Funnell ([12:45])
• On giving patients ownership:
  • “Begin every visit with asking the patients what they need to accomplish during that visit… that can actually shorten the visit.”
    — Martha Funnell ([16:55])
• A team approach is essential:
  • “Nobody can do this alone. It truly takes a team.”
    — Martha Funnell ([19:27])

Key Takeaways for Clinicians

• Effective diabetes management for patients on a budget is feasible using lifestyle modifications, targeted monitoring, and selection of cost-effective medications.
• Motivational interviewing skills are crucial—focus on listening, individualizing care, and partnering with patients.
• Empower patients by acknowledging their role in self-management, and use the healthcare team for support.
• Adjust clinical approaches to maximize both efficiency and impact, especially under time constraints.